Am Fam Physician. 2002 Dec 15;66(12):2227-2228.
“We promised her so many times that we would not put her in a nursing home,” explained the distraught woman. She had brought her 72-year-old aunt to see KS for the third time in as many weeks. The patient had severe, progressive Alzheimer's dementia, which was becoming more and more difficult to manage. When she moved in with her niece two years earlier, she had been a welcome member in their busy family, which consisted of two high school students and their working parents. In the past few months, however, the patient had become increasingly restless and had begun to wander out of the house. On several occasions, she had been lost for several hours as the family frantically searched the neighborhood. Both times she had been found in the local grocery store, wandering around with a shopping cart full to the top. Because of the family's busy schedule, the patient had to be left alone for several hours every day, and this was causing great concern to everyone. KS explained that when families make promises to keep patients at home, what they mean is that they will care for them in the very best and safest way possible. Often the best and safest way turns out to be placing the loved one in a long-term care facility.
Pagers were going off all over the hospital, announcing “Code Blue”—a disaster alert. No one was surprised. Patients and staff had spent the past hour peering out of the windows into eerie blue-blackness, gushing winds, and torrential rain. Every few minutes the radio announcers updated the path of a tornado that was working its way through the west end of the city, doing as yet untold damage. The hospital seemed like a safe place, but the telephones were busy as everyone anxiously called home. RE, the director of the family practice residency program, took charge, and staff members reported to their assigned duty stations in preparation for casualties. Half of the residents went to the family practice center to treat the non-emergency patients who were transferred there from the emergency department. The other residents were sent to the emergency department. Everyone stayed calm amid the rumors and confusion. Sadly, one person was killed by the tornado, and several others were injured. As RE went home several hours later, he remembered how he came to work that morning, thinking about the usual budget problems. The tornado had certainly moved those worries into the background for another day. Tonight, he felt great pride that the residents, nurses, and staff had met the challenge with such professionalism.
JM, a second-year resident, was examining a 46-year-old woman who presented to the emergency department with complaints of paralysis from the neck down. She alternated between moaning, crying aloud, and rolling her head back, completely unresponsive. Her vital signs and the physical examination were normal, except for the seeming inability to move her extremities. JM reviewed her medications, noting that she was on several antipsy-chotic drugs. He then reviewed her past few hospitalizations, all of which were for chronic paranoid schizophrenia. After discussing the case with the emergency department physician, he ordered laboratory tests, including a urine drug screen. An hour later the tests came back—all normal. JM was perplexed. He was convinced that the paralysis was a conversion reaction, but he did not want to miss the more remote possibility of head injury, or even a stroke. When he went back to examine the patient, he found her complaining loudly that she had to go to the bathroom. The nurse was getting ready to catheterize her, but JM had a better idea. He pointed to the bathroom on the other side of the room. With a little assistance, his patient sat up, got out of bed, and walked over to use it. “That was more valuable than a negative CT scan of the head,” thought JM, as he put in a page to the psychiatrist on call.
KS enjoys working with medical students in the clinic. She is often amazed by the depth of their medical knowledge—and subsequently learns a thing or two that she has forgotten from basic sciences. The students excel at taking a patient's history and physical examination, but they tend to have problems with the assessment and plan. Today a third-year student, TR, presented a middle-aged man with pain in his right hip, radiating into the lateral part of the thigh. He described the symptoms in detail, including quality of the pain, severity, aggravating features, and duration. The physical examination included range of motion of the spine and leg, muscle strength, sensory examination, and reflexes. While examining the patient herself, KS began to ask the student how to differentiate between acute bursitis of the hip and back pain with nerve impingement. But TR interrupted her to add that the patient had a low-grade fever (99°F), and he was concerned about the possibility of a large abscess in the thigh. KS was a little taken aback—the thought had never crossed her mind. She quickly reminded herself that teaching a student is very different from teaching a resident. She spent a few minutes with the student, developing a differential diagnosis. They included abscess on the list—but near the bottom.
“I don't eat that much, and I keep gaining weight. It is so discouraging!” complained a frustrated 34-year-old woman. This healthy patient had scheduled an appointment with KS for her yearly Papanicolaou smear. She was very upset to find that she had gained six pounds that year, and a total of 13 pounds over the previous three years. Both of her parents and one sister had type 2 diabetes mellitus, and the young woman knew that gaining even 10 pounds increased her own risk. KS explained to her patient that only 10 extra calories each day, for 365 days, adds up to 3,500 calories, or one pound a year. Likewise, it only takes 50 extra calories a day to gain five pounds per year. Slow, steady weight gain easily can lead to 20 extra pounds in five years. While this may seem discouraging, the good news is that very small changes in diet and exercise can make a big difference. For example, one fewer soda per day will save 150 calories, or 15 pounds a year. Climbing three flights of stairs at work every day would surely burn 10 calories—another pound a year. After thinking about this advice, the patient decided to switch from whole milk to skim milk. “I have been meaning to use low-fat milk anyway,” she admitted. “I knew it would save me 40 calories a day, but I never realized that such a little change could add up to four pounds per year.”
KS was making hospital rounds with PM, a third-year resident. They had just finished seeing a man in his late 40s who suffered from all the sequelae of longstanding, poorly controlled diabetes mellitus. The patient, nearly blind and on dialysis, had just undergone a below-the-knee amputation of his right leg because of diabetic foot ulcers. He had been in the hospital for 11 days. “He is just a year or so older than I am,” commented KS, taking a minute to appreciate her own good health. As the two physicians reviewed the long list of patients together, PM noticed that nearly all of them had complications from diabetes. There were three more dialysis patients, several with foot ulcers, congestive heart failure, and a variety of infections such as pneumonia or abscesses. Many of the patients in our county hospital are uninsured. They are not able to obtain outpatient treatment early, when tight glucose control can prevent such terrible complications. KS thought to herself that today's family practice residents would have to deal with this issue throughout their careers. She hopes they will be able to find ways to get uninsured patients the preventive treatments they need.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2002 by the American Academy of Family Physicians.
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